Moorfields Eye Hospital NHS Foundation Trust

This was the first inspection of Moorfields Eye Hospital NHS Foundation Trust under the new methodology. We have rated the hospital as good overall, accounting for the delivery model of care and the large volume of activity which takes place at the City Road Hospital site.

We carried out an announced inspection between 9 - 13 May 2016. We also undertook unannounced visits during the following two weeks.

We inspected four core services: urgent and emergency care, surgery, outpatients and diagnostics, and children and young people's services. This trust operates across multiple outreach locations. Due to the unique delivery model of this organisation we inspected services at the City Road and Moorfields Eye Centre at St George's Hospital. We also inspected a range of the outreach sites as part including:

• Surgery and outpatients at Bedford Hospital
• Surgery and outpatients at Moorfields Eye Centre at St George's Hospital
• Surgery at Ealing Hospital
• Surgery at Croydon Hospital
• Surgery at Mile End Hospital
• Outpatient and diagnostics at Queen Mary's Roehampton Hospital
• Outpatient and diagnostics at Purley War Memorial Hospital
• Outpatient and diagnostics at Barking, Havering and Redbridge Hospital

Our key findings were as follows:

Safe

• Mandatory training levels in some areas were below trust targets including resuscitation training and adult life support.

At the City Road site:

• The paediatric waiting area in the A&E was unsuitable for the purpose it was being used. We saw paediatric patients and their families waiting in the main waiting area with adult ED patients.

• There was a lack of storage space for patients’ notes in ED and the administrative office was overcrowded with boxes, which presented trip hazards and a barrier to evacuation.

• In surgery, improvement was required to fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality and staff engagement in the process.

• The availability of medical records was an on-going issue and temporary notes were used until the records could be located.

• In Outpatients we found omissions in some patient records including staff signatures and record entry dates.

• Some clinic waiting areas were extremely warm at times and, although temperature monitoring took place, actions did not fully address the heat.  Space was limited and there was insufficient seating for the number of patients attending clinics.

• Availability of ‘floorwalkers’ to monitor patient wellbeing in waiting areas was limited. Staff throughout the outpatient clinics were busy and told us they rarely had time to take their full breaks during their shift.

• No emergency buzzers were available in the radiology department, which could delay staff accessing help in an emergency.

• At Moorfields Eye Centre at St George’s Hospital:

• In theatres, long standing problems with ventilation meant that at times theatre lists had to be cancelled. Air changes in one anaesthetic room did not always comply with best practice.

• The urgent care clinic reception area and treatment cubicles lacked privacy and confidentially was compromised.

• The outpatients department was crowded and the waiting area in was very cramped: the chairs for patients were very close together. There was a separate waiting area for patients in wheelchairs however this only accommodated two wheelchair users. When we visited the ceiling leaked due to heavy rain, this meant that some of the chairs could not be used as they were wet.

• Staff working in treatment areas in a corridor outside the main outpatient area were isolated.

• A service level agreement had been developed to formalise the relationship between the trust and St George's University Hospitals NHS Foundation Trust but, this was not yet agreed and in place at the time of the inspection.

• At the Bedford site;

• We observed some poor infection control practice with regards to slit lamps decontamination.

• Patients undergoing surgery under a general anaesthetic were transferred to the day surgery unit at Bedford hospital but staff caring for these patients had not received ophthalmic training.

However, we found many good examples of safe care including:

• Wards and other patient areas were clean and staff were seen to be adhering to hand hygiene policies and protocols. Audit results for cleanliness and infection prevention control demonstrated a good track record and improvements and infection rates were low.

• Adequate staffing levels and skills mix was a high priority and were planned, implemented and reviewed to keep people safe at all times. Minimal staff shortages were responded to by senior nursing leaders using internal bank staff and rarely agency staff.

• Safeguarding vulnerable adults was given sufficient priority by staff who were aware to ensure immediate safety and to discuss concerns.

• Radiation safety processes, including access to lead vests and radiation monitoring, were suitable. The environment in which radiation was used was fit for purpose and protected staff and patients from unnecessary exposure to radiation.

Effective

• Care was evidence based and services participated in local and national audit.

• Care was delivered in line with relevant national guidelines and we saw appropriate policies, procedures and clinical guidelines, which referenced these.

• Care was delivered by an experienced team of ophthalmologists and ophthalmic trained nurses delivered care and treatment based on a range of best practice guidance.

• The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Nurses and health care assistants felt well supported with good supervision and good training opportunities.

• Consent practices and records are actively monitored and reviewed to improve how people are involved in making decisions about their care and treatment.

Caring

• Feedback from people who use the service, and those who are close to them, was continually positive about the way staff treated them. Patients thought the care they receive exceeds their expectations.

• Friends and Family Test results were consistently good across surgical services.

• Staff were seen to spend time talking to patients, or those close to them to ensure they received the information in a way they could understand and were given time to ask questions.

• We observed staff providing compassionate care and treating patients with dignity and respect.

• Staff provided emotional support to patients and patients were able to access the hospital multi-faith chaplaincy services, when required. Patients also had access to the trust counselling service and the eye clinic liaison office.

• In children’s and young people’s services, staff demonstrated the relationships they developed with patient’s using the service, and their commitment to ensuring they had a positive experience.

• Complex conditions and procedures were explained to children and young people in a way that enabled them to gain a full understanding of their treatment plan and take an active role in decision making.

Responsive

• The trust met the target for the national referral to treatment pathway (RTT) target of 18 weeks for outpatient appointments. They had robust systems for monitoring RTT performance.

• The trust consistently met the 4-hour ED waiting time standard, and also measured against a locally derived 3-hour target.

• There were clear patient pathways that eased the flow of patients within the A&E. The department had implemented an ‘active triage’ system whereby patients with non-emergency conditions were referred to the urgent care clinic.

• Patients and relatives told us they appreciated having local services which meant that they didn’t have to travel far.

• The surgical services had implemented a number of improvements throughout the patient pathway, including a ‘one-stop’ nurse led assessment clinic which including investigations if needed and a live patient tracking system.

• There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets that recognised and promoted those needs.

• Patients were given the flexibility to access services in a way and at a time that suited them.

• Outpatients clinics at City Road clinics were frequently overbooked and finished late. Patients consequently had a long waiting time in clinics and the hospital did not have a system in place to keep patients informed about the waiting time and did not monitor this performance data.

• In outpatients at City Road patients were seen in open bays within clinic areas. In some clinics this resulted in a lot of noise and it was difficult to hear what was being said by both patients and staff. At times these areas became very busy, with no seating availability for patients and relatives.

• At St George's there was no signage or information available for patients about waiting times and this meant that patients did not know how long they would need to wait. The department did not monitor this performance data.

• At St George's the main outpatient reception area was situated so that patient’s confidentiality and privacy was maintained. However, the reception area where patients booked into the UCC was situated next to the waiting area close to where patients sat, which meant that patients privacy and confidentially was compromised.
• Cancellation rates were high for hospital cancelled appointments in Moorfields South (both St George’s and Croydon).
• Service planning for satelite clinics at Moorfields North required improvement.  We observed these clinics were often overbooked due to the lack of a system for knowing when consultants were on leave. We were told that at Moorfields Queen Mary’s Hospital clinics were often cancelled at very short notice and that patients were not always informed and turned up for their  appointment. We were informed this happened at least one a month.

Well Led

• There were a clear set of vision and values within the surgical services that were driven by quality care and safety. Staff were clear of their involvement in delivering these objectives.
• We found a cohesive and supportive leadership team who functioned effectively, with well-established members of staff. Staff were complimentary about the support they received from their seniors and commented that they were visible and approachable. Structures, processes and systems were in place to ensure information sharing across the trust was effective.
• There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the trust.
• There are high levels of staff satisfaction across all equality groups. Staff were proud of the organisation as a place to work and spoke highly of the culture and opportunities.
• There was good governance and quality measurement. Numerous audits were undertaken regularly, including quality and safety audits.
• There were good risk management processes in place and risks were identified and acted upon.

However;

• Key issues relating to flow within the outpatient clinics, such as patient waiting times and clinics overrunning, were not formally monitored by the leadership team and therefore the benefit of any service changes could not be effectively assessed.

• A service level agreement had been developed to formalise the relationship between the trust and St George's University Hospitals NHS Foundation Trust but, this was not yet agreed and in place at the time of the inspection.

• We were concerned that there was not a robust governance system around SLA's with partner organisations, which resulted in a lack of formal mechanisms or powers to drive improvement or make changes where required.

• The senior leadership team were open about the challenges the services at Moorfields Eye Centre at St George's Hospital faced and recognised the importance of improving the environment in which the service was provided. We saw evidence of a transformation programme to relocate patients, however there were no firm plans in place to improve the environment.

• In outpatients at St George’s senior staff identified issues with the current environment and identified re-providing the services at St George’s the means to addressing this. The trust advised us of its short/medium term plans to address its current unsuitability.

We saw several areas of outstanding practice including:

• The development of staff skills, competence and knowledge, and development of extended nursing and allied health professional roles. Staff reported that they felt well supported and received good training opportunities.
• There was an extensive research portfolio, which was recognised at a UK and global level, directly benefiting patients.
• There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the services, and across the Moorfields network. For example the Bedford team worked closely with a group of local optometrists and operated a system called Bedford Shared Care Cataract Pathway.
• The organisation had taken a pivotal role in the development of ophthalmic services, as the lead in one of the hospital vanguard systems selected by NHS England to develop new models of care.
• We noted the trust had made significant investments in leadership and quality improvement, and had invited international speakers to attend a specialist event following our inspection.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Address the lack of storage space for patients’ notes in ED and the administrative office and remove barriers to evacuation.
• Fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality and staff engagement in the process, across the organisation.
• Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO five steps to safer surgery checklist to guide improvement.
• Take action to ensure the environment in theatres is safe and meets with national guidance.
• Reduce the number of mixed sex breaches at the St George's site.
• Ensure that the quality and safety of the outpatients and surgical services at Moorfields at St George's are fully assessed, monitored and improved.
• Ensure that all risks related to patient safety in outpatients and surgical services at Moorfields at St George's are fully recorded with actions to mitigate them.
• Address the environmental conditions of outpatients at the St George’s site.
• Ensure that the quality and safety of the outpatients service at the City Road site are fully monitored, including patient waiting times and clinic finish times.
• Ensure that risks relating to patient waiting times are fully mitigated.
• Ensure that patient records are fully and legibly completed, including staff signatures, record entry dates and documentation errors are correctly marked.
• Review the governance process around Service Level Agreements with partner organisations, and ensure these fit the existing and future models of care delivery.

​In addition the trust should:

• Ensure all policies and procedures are up to date and staff receive training as required for specific roles.
• Improve the uptake of appraisals and ensure all staff are aware of their responsibilities in relation to the Mental Capacity Act 2005.
• Ensure all staff complete all aspects of mandatory training.
• Ensure all staff are aware of the incident reporting process.
• Ensure all staff have knowledge and awareness of the duty of candour principles.
• Ensure all anaesthetic equipment is checked and checks are recorded.
• Reduce the theatre cancellation rate.
• Consider how the theatre environment at St George's Hospital site could be made more child friendly.
• Ensure the trust is responsive to any issues of bullying and harassment raised. 
• Ensure patient's records are available when they arrive to attend an appointment.
• Improve recording of risks and ensure all information is included on risk registers.
• Improve engagement with patients, staff and members of the public in service development/improvement.
• Address issues relating to flow within the outpatient clinics, such as patient waiting times and clinics overrunning.
• Ensure emergency buzzers are available in radiology.
• Ensure staff are aware of the electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability in the outpatients department.
• Look for ways to improve patient privacy in the outpatient department, A&E and day case wards.
• Repair the ventilation system within the A&E at the City Road site.
• Consider implementing the business plan for an electronic record system and scanning of casualty cards. This will free up space within the administration office and eliminate the risk of trips.
• Improve the waiting area for children and young people in the main A&E.
• Consider improving the checklist for the difficult airway trollies in the recovery areas to include equipment and expiry date checks.
• Ensure staff have the correct training and implement formalised systems to monitor and record staff training information for paediatrics within the theatre department.
• Develop a strategy for services for children and young people and consider how reporting about plans, priorities and the quality and safety of the service could be improved.
• Ensure that the environment of the outpatient department is routinely monitored and appropriate actions are taken to ensure patient safety, comfort and welfare.
• Consider how signage in the satellite locations could be improved for people with visual impairment.
• Ensure the service level agreement between Moorfields Eye Hospital NHS Foundation Trust and St George’s University Hospitals NHS Foundation Trust is finalised and implemented to ensure medical cover and estates management are working effectively.

Professor Sir Mike Richards

Chief Inspector of Hospitals